BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 551 of 2019
Date of Institution : 17.9.2019
Date of Decision : 06.09.2021.
Chiranji Lal Sharma aged about 36 years son of Shri Radhey Shyam Sharma, resident of Gali Moman Numberdar Wali, Bhadra Bazar, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
- Indian Bank, Seth Nanak Chand Tula Ram Jhuthra Trust Building, Surkhab Chowk, Hisar Road, Sirsa through its Branch Manager, Sirsa.
- Good Health TPA Services Ltd., Plot No.49, Nagarjuna Hills, Punjagutta, Hyderabad- 500082 through its M.D/ authorized person.
- United India Insurance Co. Ltd., City Thana Road, Sirsa, Tehsil and Distt. Sirsa through Division Manager.
- United India Insurance Co. Ltd., Catholic Centre, No.64, Armanian Street, Chennai- 600001 through Chief Manager.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. JASWANT SINGH………………PRESIDENT
SMT. SUKHDEEP KAUR………… MEMBER
Present: Sh. N.K. Daroliya, Advocate for the complainant.
Sh. A.K. Gupta, Advocate for opposite party no.1.
Sh. Kapil Sharma, Advocate for opposite parties no.3 and 4.
Opposite party no.2 exparte.
ORDER
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 (after amendment as under Section 35 of the Consumer Protection Act, 2019) against the opposite parties (hereinafter referred to as Ops) on the averments that complainant was/ is the consumer of op no.1 bank since long and also maintaining his account with op no.1 bearing account No. 876163559. As per the local officials of the op no.1, there was an scheme in their bank under which the customers can get health insurance on nominal premium and allured the complainant to purchase health policy namely Arogya Raksha. The complainant purchased the insurance policy covering the medical risk to his life from ops bearing No.10500201748410000534903 which was effective from 25.5.2017 to 30.4.2018 and this policy was issued by ops no.3 and 4 after receiving Rs.2327/- as premium of policy and after thorough enquiry/ examination by the ops as well as medical officer qua the health of complainant and as the complainant was found as medically fit person, the ops supplied the insurance policy. That complainant deposited the premium amount against the receipt and never committed any default in the payment of premium amount. That on 15.2.2018 at night at about 10.00 P.M, the condition of complainant became serious with the complains of retros ternal chest pain with uneasiness and on the next morning, the complainant was firstly taken to Jiwan Jyoti Hospital, Sirsa where he was given primary treatment and then was referred to Poonia Hospital where the complainant was admitted and undergone medical checkup, tests etc. He was treated by Dr. Mandeep Garg of said hospital and accordingly the complainant undergone the treatment/ surgery/ CAG and primary PCI done to RCA on 16.2.2018 and remained admitted up to 19.2.2018. The complainant was suffering from cardio problem and during hospitalization, he was given antiplantelet, anticoagulant with other supportive treatment. That complainant immediately informed to the concerned officer of the local office of ops no.3 and 4. Thereafter, the complainant through his banker i.e. op no.1 accordingly applied for the hospitalization claim amount of medical treatment and submitted the medical bills of Rs.1,18,666/- but the ops acting in a gross unfair manner refused to admit the claim of complainant. It is further averred that complainant also filed a consumer complaint bearing No.268 on 29.102018 in which the ops had taken the plea that they had not repudiated the claim of complainant. Accordingly, the complaint was disposed of by this Hon’ble Forum with the direction to the complainant to approach the ops and ops were directed to decide t he matter in specific time given in the order dated 27.5.2019. That complainant had completed all the formalities and provided all the documents with the ops but ops paid only Rs.80,000/- on 10.7.2019 directly in his account without explaining the cogent reason for not making the remaining amount of claim i.e. Rs.38,666/-. That due to act and conduct of the ops, complainant has undergone much mental tension, harassment. Hence, this complaint.
2. On notice, opposite parties no.1, 3 and 4 appeared. OP no.1 filed written version taking certain preliminary objections. It is submitted complainant has no cause of action against the answering op. The complainant has lodged a claim under the health policy i.e. Arogya Raksha which was issued by United India Insurance Company. The policy was duly issued to the complainant. The complainant had submitted the claim form and bills in respect of his illness which were duly sent to the TPA of United India Insurance Company Ltd. as and when the claim form was received by op no.1. As per averments in the complaint, the complainant has already received Rs.80,000/- from the insurance company, so there is no cause of action against the answering op in any way. The complaint if any lies against the insurance company only. That complainant is estopped by his own act and conduct to file the present complaint and complaint is bad for mis joinder and non joinder of necessary parties. On merits, while denying all other contents of the complaint and reiterating the preliminary objections, it is submitted that United India Insurance Company Ltd. is a Nationalized company and the bank has simply charged the premium from the complainant and has passed it on to the company and company issued a health policy. That bank has simply charged the premium from the complainant and has passed it to the company and the company issued a health policy. There is no lien of contract between the answering op and the complainant. The bank provides the facility of issuing the health policies to its customer on reduced rates. The policy has to be issued by the concerned insurance company, which was issued and the premium was credited to the account of insurance company by the bank. The bank is not concerned in any way in the settlement of the claims and in case the claim of complainant has not been settled, then the insurance company is answerable. The bank has nothing to do with the same. Remaining contents of complaint are also denied.
3. Notice was issued to the op no.2 through registered letter/ cover but same did not receive back and since period of more than 30 days elapsed but none appeared on behalf of op no.2, therefore, op no.2 was proceeded against exparte.
4. Ops no.3 and 4 filed written version taking certain preliminary objections regarding maintainability, estoppal, jurisdiction, non joinder and mis joinder of necessary parties and no deficiency etc. It is also submitted that answering ops have issued Indian Bank Arogya Raksha (Group Health Insurance Scheme) policy No.0105002817P111615287 w.e.f. 25.5.2017 to 30.4.2018 covering the risk of Rs.1,00,000/- to the insured and his family mentioned in the policy. The answering ops have paid Rs.80,000/- to the complainant as per terms and conditions of Special Condition attached and forming part of insurance policy and clause No.1.2.1(d) according to which i.e. actual expenses incurred or 80% of sum insured whichever is less for all major surgeries as specified by doctor is to be paid. Therefore, the claim of complainant was settled/ paid as per the terms and conditions of the policy. On merits, it is also submitted that earlier the complainant filed consumer complaint in which the Hon’ble Forum directed the complainant to submit the documents demanded by insurance company and further directed to the insurance company to settle the claim within a period of 60 days from the date of receipt of document from the complainant. Therefore, the answering ops after receiving the documents from the complainant, settled/ paid the amount as per terms and conditions of insurance policy. The complainant is not entitled for the remaining amount i.e. Rs.38,666/- as alleged. Remaining contents of complaint are also denied and prayer for dismissal of complaint made.
5. The parties then led their respective evidence.
6. The complainant has tendered into evidence his affidavit Ex.CW1/A, copy of policy cum certificate Ex.C1, copy of receipt of premium Ex.C2, copy of card Ex.C3, copy of coronary angioplasty report Ex.C4, copy of coronary angioplasty report Ex.C5, copies of receipts and bills Ex.C8 to Ex.C21, copy of PAN card Ex.C22, copy of adhar card Ex.C23, copy of policy cum certificate of insurance Ex.C24, copy of premium receipt Ex.C25, copy of case summary/ discharge slip Ex.C26, copies of laboratory reports Ex.C27 to Ex.C29, copy of letter dated 12.3.2018 Ex.C30, copy of letter dated 26.9.2018 Ex.C31, copy of application Ex.C32, copy of order dated 3.9.2019 regarding withdrawal of execution Ex.C33, copy of entry of dispatch register Ex.C34, copy of order dated 27.5.2019 Ex.C35, copy of pass book Ex.C36.
7. On the other hand, op no.1 has tendered in evidence affidavit of Sh. Balram Bhadu, Senior Divisional Manager as Ex.R1, copy of letter dated 8.7.2019 Ex.R2 regarding settlement of claim Ex.R2, copy of insurance policy Ex.R3.
8. Ops no.3 and 4 have tendered in evidence affidavit of Sh. Pankaj Kumar, Branch Manager as Ex.R4.
9. We have heard learned counsel for the parties and have perused the case file carefully.
10. It is an admitted fact that complainant is maintaining/ having account with op no.1 bank and on coming to know about the health policy namely Arogya Raksha, complainant purchased insurance policy covering medical risk to his life from ops against payment of premium of Rs.2327/- and said policy was effective from 25.5.2017 to 30.4.2018. According to complainant, all of sudden on 15.2.2018 i.e. during subsistence of the policy, the condition of complainant became serious as he felt chest pain with uneasiness and he was taken to Poonia Hospital, Sirsa where Dr. Mandeep Garg (MD) conducted surgery on his person on 16.2.2018 as he was suffering from cardio problem and during his hospitalization, he was given antiplanelet anticoagulant with other supportive treatment and remained admitted up to 19.2.2018. The complainant spent an amount of Rs.1,18,666/- on his treatment but despite his request to reimburse hospitalization charges made through op no.1, the ops insurance company refused to pay any claim to the complainant. It is relevant and an admitted fact that earlier also complainant filed a consumer complaint bearing No.268 of 2018 in which the ops have taken a plea that they have not repudiated the claim of complainant and during the course of arguments, learned counsel for ops no.3 and 4 has stated at bar that ops no.3 and 4 insurance company have closed file due to non furnishing of information by the complainant to the TPA and claim of complainant has not been settled on merit nor same has been repudiated so far. On the other hand, learned counsel for complainant stated at bar that complainant is ready to furnish information as per requirement of the insurance company and has no objection in case complaint is disposed off with the direction to the complainant to furnish the information and ops are directed to settle and pay the claim as per terms and conditions of the policy. Accordingly, the earlier complaint titled as Chiranji Lal Vs. Indian Bank etc. bearing No.268 of 2018 was disposed off on 27.5.2019 with a direction to the complainant to supply information/ explanation for submitting delayed information and lodging claim with the ops and to submit all required documents which are necessary for settlement of claim to the insurance company within 15 days from the date of receipt of copy of the order. The insurance company was directed to settle and pay the claim of complainant within 60 days from the date of receipt of documents from the complainant. It was also made clear that in case claim is not settled, the complainant shall be at liberty to approach this Forum on the same cause of action.
11. Learned counsel for complainant has contended that complainant has spent an amount of Rs.1,18,666/- on his above said treatment/ surgery but ops no.3 and 4 have paid only an amount of Rs.80,000/- to him and they have wrongly withheld the remaining amount of Rs.38,666/- and complainant is also entitled to this amount of Rs.38,666/- alongwith interest and compensation for harassment.
12. Learned counsel for ops no.3 and 4 have contended that in terms of the order dated 27.05.2019, they have settled and paid the claim amount of Rs.80,000/- to the complainant as per terms and conditions of the insurance policy and ops are not liable to pay any other amount to the complainant.
13. From the perusal of the policy-cum-certificate Ex.C1 placed on file by complainant, it is evident that complainant purchased the policy in question covering medical risk for a sum of Rs.1,00,000/- and said policy was effective from 1.5.2018 to 30.4.2019. It is also an admitted fact that during subsistence of the policy in question, complainant felt chest pain on 15.2.2018 and he was taken to Poonia Hospital, Sirsa where Dr. Mandeep Garg treated him and conducted surgery on the person of complainant and complainant spent an amount of Rs.1,18,666/- on his treatment including hospitalization charges. It is also an admitted fact that after passing of order dated 27.5.2019 in earlier complaint on same cause of action filed by complainant, the ops have settled and paid the claim amount of Rs.80,000/- to the complainant on 10.7.2019 which fact is also not disputed. The ops have also placed on file copy of letter dated 8.7.2019 as Ex.R2 written to the complainant regarding settlement of his claim and that amount has been transferred on 8.7.2019 in his bank account. According to the ops, the said amount has been paid to the complainant as per terms and conditions of policy and they have relied upon clause No.1.2.1 (d) of Indian Bank Arogya Raksha (Group Health Insurance Scheme) Policy, which provides as under:-
1.2.1 Expenses in respect of the following specified illnesses will be restricted as detailed below:-
Hospitalisation Benefits | Limits for Each Hospitalisation |
d. All major surgery- as specified by doctor | d. Actual expenses incurred or 80% of the SI whichever is less |
* Major surgeries include Cardiac surgeries, Brain Tumor surgeries, Pacemaker implantation for sick sinus syndrome, Cancer surgeries, Hip, Knee, joint replacement surgery, Organ Transplant.
14. From the above said clause No.1.2.1 (d) of the policy in question, it is clear that for cardiac surgery which the complainant underwent, he was entitled to the actual expenses incurred or 80% of the sum insured whichever is less. Admittedly, the sum insured in the policy is Rs.1,00,000/- and according to complainant himself, he has spent an amount of Rs.1,18,666/- on his treatment/ surgery, therefore, as per terms and conditions of the policy, he was entitled to 80% of the sum insured of Rs.one lac i.e. Rs. eighty thousand as the amount cannot exceed sum insured and as per above said clause, the ops were liable to pay actual expenses incurred or 80% of the sum insured whichever is less. So, the ops have rightly paid the amount of Rs.80,000/- to the complainant as per terms and conditions of the policy in question and complainant is not entitled to any other remaining amount.
15. Thus, as a sequel to our above discussion, we find no merit in the present complaint and same is hereby dismissed but with no order as to costs. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Commission. Member President,
Dated:06.09.2021. District Consumer Disputes
Redressal Commission, Sirsa.
